Promoting nurse‐led behaviour change interventions to prevent cardiovascular disease in disadvantaged communities: A scoping review

Abstract Cardiovascular diseases (CVD) are the leading cause of death worldwide and they disproportionally affect people living in disadvantaged communities. Nurse‐led behaviour change interventions have shown great promise in preventing CVD. However, knowledge regarding the impact and nature of such interventions in disadvantaged communities is limited. This review aimed to address this knowledge gap. A six‐stage scoping review framework developed by Arksey and O'Malley, with revisions by Levac et al., was used. The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses‐Extension for Scoping Reviews (PRISMA‐ScR). Three electronic databases were searched (PUBMED/MEDLINE, CINAHL Plus, and Cochrane CENTRAL), and included studies were analysed using Braun and Clarke's ‘Thematic Analysis’ approach. Initial searches yielded 952 papers and 30 studies were included in the review following duplicate, title/abstract, and full‐text screening. The included studies indicate that nurse‐led behaviour change primary prevention interventions in disadvantaged areas are largely effective; albeit the considerable variety of intervention approaches, study populations and outcome measures used to date make it difficult to ascertain this. Other identified key areas in the promotion of nurse‐led behaviour change included tailoring interventions to specific populations, providing adequate training for nurses, overcoming patient access difficulties and encouraging patient engagement. Overall, the findings indicate that nurse‐led behaviour change interventions for high‐risk CVD patients in disadvantaged areas show much promise, although there is considerable variety in the interventions employed and studied to date. Further research is needed to examine the unique barriers and facilitators of interventions for specific disadvantaged groups.


| INTRODUC TI ON
Cardiovascular diseases (CVD) are the primary cause of death globally and account for an estimated 17.9 million deaths each year (Mensah et al., 2019;Smyth et al., 2017). Two-thirds of cardiovascular disease, deaths and cases are attributable to preventable risk factors (Jennings, 2014), and low socio-economic status is an established and important risk factor for CVD development (Franks et al., 2011;Schultz et al., 2018). While policy guidelines for the management of high-risk CVD patients have been proposed (Piepoli et al., 2016), they have not yet been properly established in clinical practice (Kotseva et al., 2019). Nonetheless, research indicates that nurse-led primary prevention interventions show promise with regard to improving CVD patients' health outcomes. The World Health Organisation identifies greater utilisation of nurses, rather than physicians, as a potentially effective strategy for improving CVD care access in deprived areas (Schultz et al., 2018), and it has been claimed that nurses are ideally positioned to lead CVD prevention initiatives, as they are often the primary point of contact with patients and their families (Berra, 2011).
The EUROACTION trial (2003EUROACTION trial ( -2006 meanwhile showed that a 16week nurse-coordinated, multidisciplinary, family-based programme could be more effective than usual care in preventing CVD (Wood et al., 2008), and a recent systematic review demonstrated that community-based nurse-led interventions are largely effective in reducing CVD risk (Tan et al., 2020). Tan et al.'s findings show that CVD risk can be reduced with respect to a number of outcomes including HbA1c reductions for diabetes patients, achievement of desired blood pressure goals for hypertensive patients and improvements around hyperlipidaemia patients' self-reported dietary intake. Furthermore, Tan et al. indicate that effective prevention interventions apply a targeted approach towards underserved populations, and that appropriate funding, thoughtful design and training opportunities for nurses are needed to ensure optimal intervention outcomes.
However, knowledge regarding the impact and defining characteristics of nurse-led behaviour change interventions for patients with high CVD risk in disadvantaged communities is lacking. This study aimed to address this problem and to inform clinical practice, policy and future research by examining the question; "How can nurse-led behaviour change primary prevention initiatives enhance health outcomes among high CVD risk patients in disadvantaged communities?"

| ME THODS
A scoping review methodology using the six-stage process developed by Arksey and O'Malley (Arksey & O'Malley, 2005), with revisions by Levac et al. (2010) was chosen to achieve an overview of existing literature on the topic of nurse-led behaviour change interventions for high CVD risk patients in disadvantaged communities. Scoping reviews are well suited to the study of relatively poorly understood topics like this, particularly with regard to collating relevant literature in the area, and identifying key ideas and research gaps (Arksey & O'Malley, 2005).

| Stage 1: Identifying the research question
This study's research question was formulated by identifying gaps in the existing literature and by consulting with healthcare professionals working in the areas of primary care, nursing, public health and health promotion. During these processes, consensus emerged that prevention of chronic diseases such as CVD among high-risk groups is a population health priority, and that patients living in disadvantaged areas have a particularly high risk of developing CVD. It was also agreed that nurse-led interventions show considerable promise with regard to tackling these issues. Thus, the following research question was formulated: "How can nurse-led behaviour change primary prevention initiatives enhance health outcomes among high CVD risk patients in disadvantaged communities?" The following definitions were used: Nurse-led = Where nurses are the primary healthcare providers responsible for leading, coordinating, managing, delivering or facilitating patient care. studied to date. Further research is needed to examine the unique barriers and facilitators of interventions for specific disadvantaged groups.

K E Y W O R D S cardiovascular diseases, disadvantaged, health behaviour, practice patterns, nurses
What is known about this topic?
• Cardiovascular diseases' (CVD) impacts on mortality and quality of life are considerable, but nurse-led behaviour change interventions to prevent CVD show promise.
Still, understanding of nurse-led behaviour change interventions for CVD patients in disadvantaged communities is limited.

What this paper adds?
• This study shows that primary prevention interventions have potential, although further research is needed to better understand the unique barriers and facilitators of these for specific disadvantaged groups.
Disadvantaged Community = An area of low socio-economic status. We chose to focus on income as an indicator of socio-economic status, as some studies were unclear about how other factors (e.g. belonging to an ethnic minority group) could relate to socioeconomic status (Galobardes et al., 2007).

| Stage 2: Identifying relevant studies
Initial searching of key databases was performed using multiple terms, and a short reading list was generated containing relevant studies. Search terms and MeSH terms were then generated by examining the studies' titles, abstracts and methodologies (See Figure 1). These search / MeSH terms were then used to conduct a second and more thorough literature search of electronic databases (i.e. "PUBMED/MEDLINE", "CINAHL Plus" and "Cochrane CENTRAL"). Additional studies were added by searching grey literature using "Google" and by hand-searching the reference sections of identified key literature.

| Stage 3: Selecting studies
The study selection process consisted of a title / abstract review followed by a full-text review. The selection pathway is summarised by the accompanying "PRISMA extension for Scoping Reviews" (PRISMA ScR) flow diagram ( Figure 2). As is tradition with scoping reviews, both peer-reviewed and grey literatures were included to facilitate incorporation of diverse research methodologies (Arksey & O'Malley, 2005), as were studies which aimed to reduce modifiable CVD risk factors including uncontrolled diabetes mellitus, hypertension, hypercholesterolemia, poor diet, lack of exercise, smoking and excessive alcohol consumption (Yusuf et al., 2004). Study protocols were not included. EndNote X9 software was used to assist in the screening process by tracking studies and managing citations.
The studies were selected according to predetermined inclusion and exclusion criteria which are outlined below:  Table 2).

| Stage 5: Collating, summarising and reporting results
Data from the included studies was collated, presented and analysed to provide an overview of the literature. From this, major themes in the literature regarding practice nurse-led CVD primary prevention behaviour change interventions were identified using Braun and Clarke's "Thematic Analysis" approach (Braun & Clarke, 2006).

| Stage 6: Consultation
As per the guidance of Levac et al. (Levac et al., 2010), consultation with experts in the areas of primary care, nursing, public health and health promotion was conducted, and studies were included/ excluded and interpreted based on their advice.

| Search results
Initial searching of "PUBMED/MEDLINE", "CINAHL Plus" and "Cochrane CENTRAL" yielded 947 results, while hand-searching of grey literature and the references of key literature identified five more studies. Duplicates were then removed (n = 93), and the titles / abstracts of 859 papers were screened for relevance.

| Older patients
Prevention interventions were also designed to meet the needs of specific patient groups. For instance, some studies targeted care for older populations (Jeong et al., 2018;Kim et al., 2014;Ko et al., 2011;Murphy et al., 2015;Yang et al., 2016). It was recognised that older patients are particularly vulnerable, as they often live alone (Jeong et al., 2018;Kim et al., 2014;Yang et al., 2016), suffer more frequently from cognitive and mood problems (Jeong et al., 2018), are more likely to have poor cardiovascular health (Murphy et al., 2015;Yang et al., 2016) and may have poorer health literacy and digital literacy (Jeong et al., 2018). Telephone supports were often used to combat these issues and were shown to be cost-effective and useful (Jeong et al., 2018;Kim et al., 2014;Ko et al., 2011;Yang et al., 2016). The success of telephone supports was largely attributed to the fact that older adults are familiar with the technology, and because frequent contact of this nature can help develop trust in patient-care provider relationships (Jeong et al., 2018;Kim et al., 2014). Visiting nurses were also employed to combat travel-related care access difficulties among this population (Kim et al., 2014;Ko et al., 2011;Yang et al., 2016), longer sessions were used to afford older people more time when learning as part of educational initiatives (Ko et al., 2011) and older patients were shown to enjoy using logs to track progress towards and achievement of goals (Murphy et al., 2015).

| Patients with Low-Literacy/education
Five studies noted challenges when working with populations that have low health literacy and/or low educational status (Allen et al., 2011;El Fakiri et al., 2008;Jeong et al., 2018;Mertens et al., 2014;Murphy et al., 2015). Included studies suggest that patients with lower educational levels are less likely to participate in health education programmes (El Fakiri et al., 2008;Jeong et al., 2018) and prevention interventions were designed to counter this issue using accessible resources and strategies including low literacy guides (Allen et al., 2011;Crowley et al., 2013;Murphy et al., 2015) and interview rather than written questionnaire data collection methods (Mertens et al., 2014).

| Gender
The importance of making interventions attractive to both genders was not considered in most studies. However, one study noted that this issue should be addressed in future research, as more women are recruited for weight management programmes (McRobbie et al., 2016). Another study found that motivational interviewing interventions may be more effective in reducing alcohol and drug use among men rather than among women (Mertens et al., 2014), and one study involved implementing an intervention for pregnant women (Derksen et al., 2019).

| Cost-effectiveness
Cost-effectiveness was rarely examined by the included studies.
However, one nurse practitioner and community health worker (CHW)-led intervention was found to be a cost-effective strategy for reducing cardiovascular risk in minority, underserved populations (Allen et al., 2011;Allen et al., 2014), whereas telephone supports (Brown et al., 2011;Jeong et al., 2018), short-term interventions (Beckham, 2007) and visiting nurses (Kim et al., 2014;Ko et al., 2011) were all reported as low-cost initiatives. Two studies meanwhile reported programme costs as a participation barrier (Allen et al., 2011;Gibson, 2008).

| Staff training
3.6.1 | Highly trained staff Two studies used highly trained specialist nurses (Allen et al., 2011;Dean et al., 2014). One of these also employed a consultant with specialist expertise in hypertension for assistance (Dean et al., 2014), and the other used experienced nurse interventionalists rather than clinic nurses (Crowley et al., 2013). The studies' findings indicate that while highly trained staff may be more reliable, their availability to deliver prevention interventions in resource-constrained areas may be lacking.
Nurse training was often led and supported by senior and expert care staff on an ongoing basis (Shishani et al., 2019). Training benefits were largely unreported in the included studies. However, one study involving training at a rural community health centre was deemed effective in terms of both costs and improving nurses' knowledge / skill sets (Weiler & Tirrell, 2007).

| Telephone/telemonitoring
Eleven studies used telephone technology initiatives. Telephone was used both as a primary and as an additional form of contact with patients (Crowley et al., 2013;Fischer et al., 2012;Jeong et al., 2018;Jordan et al., 2011); as part of follow-up programmes (Dean et al., 2014;Piñeiro et al., 2020;Waller et al., 2016;Yang et al., 2016); and as a patient reminder tool between coaching sessions and screenings (McRobbie et al., 2016;Murphy et al., 2015).
The studies indicate that telephone contact, as opposed to faceto-face contact, may decrease costs, and improve resource utilisation (Fischer et al., 2012;Jeong et al., 2018;Jordan et al., 2011).
Telephone is also an accessible and familiar medium (Jeong et al., 2018;Jordan et al., 2011), and so it may facilitate more frequent contact between care providers and patients (Jeong et al., 2018;Kim et al., 2014), the overcoming of issues regarding travel-and / or time-related care access restrictions (Jordan et al., 2011) and a greater sense of person-centredness in sessions (Crowley et al., 2013;Jordan et al., 2011). Meanwhile, three studies used telemonitoring to combat limited resource access (Carter et al., 2011;Jeong et al., 2018;McKee et al., 2011), and this approach enabled frequent contact and closer relationships between patients and nurses (Carter et al., 2011).

| Alternative locations
Difficulties which low-income patients can experience accessing care were also tackled using home-based programmes and alternative settings. One study used CHW home visits (Gary et al., 2009) and four studies employed visiting nurses (Kim et al., 2014;Ko et al., 2011;McKee et al., 2011;Yang et al., 2016). Interventions were conducted at various alternate locations including: in community halls and hotels (Gibson, 2008); in religious settings (Brown et al., 2011;Monay et al., 2010); in schools (Brown et al., 2011); and on worksites (Murphy et al., 2015). The studies suggest that it is important that such locations are conveniently located and are accessible via public transportation (Murphy et al., 2015), as patients may feel at ease in familiar locations (Gibson, 2008), and leaders in community sites may be able to help care workers understand the sociocultural contexts of patients' communities (Murphy et al., 2015).

| Brief interventions
Included studies also showed that brief interventions can overcome barriers posed by time commitments. Numerous studies outlined brief intervention resources and strategies including clinical decision support tools (Bachhuber et al., 2017), brief motivational interviewing techniques (Mertens et al., 2014), brief advice interventions (Piñeiro et al., 2020) and short questionnaires (Waller et al., 2016).

| Patient engagement
3.8.1 | Patient enrolment/interaction/ retention problems Numerous studies outlined patient engagement issues, their causes and strategies to overcome such problems (Brown et al., 2011;Dean et al., 2014;Froelicher et al., 2010;Gary et al., 2009;McRobbie et al., 2016;Mertens et al., 2014;Murphy et al., 2015). Difficulties regarding patient enrolment, interaction, and retention were common among the included studies, and competing everyday demands were cited as being the biggest cause of such issues (Froelicher et al., 2010). The included studies outline numerous initiatives and approaches that may counter problems like this including: the hiring of nurses who are familiar to (Dean et al., 2014)

| Incentives
Incentives were also used in some studies to promote patient engagement with programmes. For instance, patients were offered contribution towards travel expenses (McRobbie et al., 2016), payment for attended sessions (Froelicher et al., 2010;McKee et al., 2011), gift cards (Mertens et al., 2014;Piñeiro et al., 2020) and opportunities to win prizes (Froelicher et al., 2010;Shishani et al., 2019). Several studies also outlined difficulties in retaining and recruiting nurses due to high demand for nurses in underserved, low-income settings (Gary et al., 2009;Ko et al., 2011;Mertens et al., 2014). Staff incentives to address issues like this were not frequently discussed, but one study did note a smoking cessation intervention providing incentives for staff to distribute "quit kits" encouraging smoking cessation (Shishani et al., 2019).

| Family/friends support
Some primary prevention interventions involved patients' family and friends to overcome patient engagement issues and often with positive results. Successful initiatives of this nature included: patient participation in social networking modules (Carter et al., 2011); group education sessions (Murphy et al., 2015); patient grouping according to location to create feelings of neighbourhood support (Brown et al., 2011); and nurse-led conversation regarding the accomplishments of familiar nearby participants to motivate patients (Yang et al., 2016). However, it is also worth mentioning that involving family and friend supports may be difficult (Weiler & Tirrell, 2007), although night / weekend programmes and explicit invitations for family / friends may address problems in this regard (Weiler & Tirrell, 2007). It is also worth noting that in some circumstances, family and friend involvement may impede intervention success. For example, family / friends may discourage patients from achieving intervention goals (e.g. smoking cessation) (Derksen et al., 2019).

| Barriers faced by nurses
There was a lack of research regarding intervention barriers and facilitators. In studies which did examine this, barriers nurses faced included difficulty operating within existing GP practice hierarchies (Jansen et al., 2007), resource limitations (Ko et al., 2011), unmotivated patients (Derksen et al., 2019;El Fakiri et al., 2008)  those reported in previous literature largely concern the nature and quality of relationships between nurses, patients and patients' communities (Michálková et al., 2016;Tan et al., 2020;Westland et al., 2018), as well as the availability of nurse resources (e.g. time, IT, physical space, training, support from physician peers) (Berra, 2011;Westland et al., 2020). Lastly, this review's findings are comparatively limited in the sense that patients' opinions and experiences of interventions were not widely examined by the included studies. Previous research has shown that patient engagement is affected by various psychological factors including patients' perceived physical and emotional benefits of interventions, as well as their personal level of goal attainment (Westland et al., 2019), and this review did not focus on this aspect.

| Methodological considerations
The scoping review methodology used in this study allowed for broad mapping of the literature around nurse-led behaviour change interventions to prevent CVD in disadvantaged communities. Arksey and O′Malley's scoping review framework was also beneficial, as it ensured that the study's research question development, study selection and data interpretation processes were conducted using a rigorous approach. The application of MeSH terms, electronic literature databases, the PRISMA ScR, Braun and Clarke's "Thematic Analysis" approach, and Levac et al.'s guidance were also helpful with regard to ensuring high methodological standards. However, this review also had limitations which should be considered. For instance, despite efforts to conduct a comprehensive literature search, it is possible that not all relevant publications were identified by the search strategy used. Furthermore, as is tradition with scoping reviews, an assessment of study quality was not conducted as we preferred to focus on mapping the findings of all relevant literature, regardless of study quality. The term "disadvantaged communities" used in this review was also quite broad. While we tried to narrow this definition by focusing on low socio-economic status using income as the primary indicator, it is worth noting that the included studies' samples often varied considerably in terms of key demographic characteristics such as ethnicity and geographical location.

| Implications for research, practice and policy making
Intervention initiatives tailored to disadvantaged groups, and strategies to overcome barriers impeding intervention success, should continue to be implemented and evaluated within health systems.
For instance, this review's findings indicate that disadvantaged populations are considerably heterogeneous, and so future implementation / evaluation of primary prevention interventions should be conducted with the unique care needs and socio-cultural contexts of specific population sub-groups in mind. More research investigating patient experiences and perspectives of interventions will be useful when it comes to identifying what these specific needs and contexts are. System-level barriers preventing nurses from delivering high-quality interventions, and strategies tackling these barriers, should also be examined more closely. This study's findings suggest that numerous initiatives including telemedicine supports, visiting nurses, appropriately timed interventions sessions, community-based supports, training, funding and incentives may be helpful with regard to addressing such issues.

| CON CLUS ION
Nurse-led behaviour change interventions for high CVD risk patients in disadvantaged communities show much promise.
However, disadvantaged populations are considerably heterogeneous in nature and future interventions may benefit from adopting approaches that are tailored to specific population sub-groups' unique care needs. More research is needed to evaluate the potential of such interventions, as well as barriers and facilitators to positive intervention outcomes.

ACK N OWLED G EM ENTS
We would like to thank the Health Research Board's Summer Student Scholarship initiative and the Health Service Executive for supporting this study. Open access funding provided by IReL.